Indicate whether claims are pre-payment and/or post-payment denials (please check both boxes, if both options apply):
Pre-Payment Denial
Post-Payment Denial
Were all claims covered under Medicare Part A and/or Medicare Part B (please check both boxes, if both options apply)?
Part A
Part B
Were all of your requests for ALJ hearing or Council review timely filed (e.g., ALJ requests for hearing must
be filed within 60 days of receiving the QIC reconsideration notice)?
Yes No
Is the amount in controversy (AIC) met for all of your appeals? For calendar year (CY) 2013-CY 2014, the
AIC required for an ALJ hearing is $140. For CY 2015-CY 2016, the AIC is $150. For CY 2017-CY 2019,
the AIC is $160.
Yes
No
Currently, are all of your requests for ALJ hearing unscheduled for an ALJ hearing (that is, you have not
received a Notice of Hearing)?
Yes
No
NOTE: If any of the above responses are marked “No,” then some of your appeals may be ineligible for SCF. Your Preliminary
Notification will state the reason(s) why some appeals will not be included in SCF.
Are any of your appeals contesting a Qualified Independent Contractor (QIC) or ALJ dismissal order?
Yes No
Do you know of any False Claims Act litigation or investigations pending against you or your organization?
Yes
No
Has the Appellant executed a settlement agreement with the United States related to False Claims Act
litigation or related conduct since January 1, 2010?
Yes
No
Have you filed for bankruptcy and/or is the appellant expected to file for bankruptcy in the future?
Yes
No
Do any of the appealed claim(s) involve equipment, items, services, drugs, or biologicals billed under
unlisted, unspecified, unclassified, or miscellaneous healthcare codes (for example, HCPCS Code J3490
Unclassified drugs; HCPCS Code K0108 Wheelchair component or accessory, not otherwise specified)?
Yes
No
NOTE: If any of the above responses are marked “Yes,” then some of your appeals may be ineligible for SCF. Your Preliminary
Notification will state the reason(s) why some appeals will not be included in SCF.
I am requesting the SCF process for my appeals that are pending an OMHA or Council review. I understand that my appeals will be
reviewed to determine what I have pending and determine which appeals will be eligible for SCF, if any. Notwithstanding, I understand it
is solely my responsibility to ensure that my appeals subject to SCF actually meet all of the SCF eligibility criteria.
I understand that once my SCF eligible appeals are identified in the Preliminary Notification, my SCF eligible appeals will be placed in a
hold status during the entirety of the SCF process. This means my appeals will not be processed for OMHA or Council assignment,
hearing, and/or decision or order until after the SCF process has concluded. I also understand that if an agreement is not reached, my
appeals will return to the OMHA or Council dockets in the order in which my request(s) for review was received.
I understand that the Centers for Medicare & Medicaid Services (CMS) is not obligated to enter into a settlement agreement with me. I also
understand that any party may decline participation in the SCF process at any time. I understand I do not have the right to appeal CMS’
declination to participate in SCF with me. Further, I understand that the U.S. Department of Justice must approve a proposed settlement
agreement involving individual appealed claims with billed charges in excess of $100,000 or an appeal of an extrapolated overpayment with
an overpayment demand amount in excess of $100,000.
I am authorized to initiate the SCF process on behalf of the appellant identified above. I attest that the information provided in this
document is true and correct to the best of my knowledge.
Appellant Signature Appellant Printed Name Date
OMHA (06/19)
PAGE 2 OF 2
